WA[A[E (Wah- Zha- Zhi)

Transcription

1 WA[A[E (Wah- Zha- Zhi) Early Learning Academy Enrollment Packet Serving children from 6 weeks to Twelve Years. Pawhuska Skiatook Hominy Fairfax Creating a Brighter Future through Education Administrative Offices 102 Buffalo Ave.

2 Hominy, OK 74056

3 CHECKLIST The following information is needed before your child s application will be considered for acceptance. Parent and/or Legal Guardian s Income verification (Pay Stub, W 2, IRS form 1040 (signed), letter from Employer, TANF, Unemployment, SSI, Foster Care Reimbursement, Unemployment Statement) Child s Immunization Record The following information is needed to complete your student s file: If Osage, Osage membership number (if applicable) If non-osage, copy of tribal membership or CDIB card Copy of Birth Certificate Copy of Social Security Card WA[A[E Early Learning Academy Center Manager: WA[A[E Early Learning Academy Center Phone Number: WA[A[E Early Learning Academy Center Fax Number:

4 ENROLLMENT INFORMATION Application : STUDENT INFORMATION Student Name: Nickname: of Birth: Native American: Yes No If yes, list Tribal Affiliation: If Osage, list Osage Membership Number: Address: City: State: Zip Code: Allergies: Special Needs: PARENT/GUARDIAN INFORMATION Parent/Guardian Name: Address: City: State: Zip Code: Primary Phone Number: Mother s Place of Employment: Work #: Mother s Cell: Father s Place of Employment: Work #: Mother s Cell: (Circle One) Do you receive Child Care Assistance from DHS? Yes No Do you receive Child Care Assistance from the Osage Nation? Yes No

5 LIST ALL INDIVIDUALS IN THE HOUSEHOLD Name Relationship to Student Age SCHOOL INFORMATION Does your student attend school or Head Start? Yes No If so, what grade will he/she be in this year? Name of School: Name of Teacher: Phone: Will your student need transportation to school? Yes No Will your student need transportation from school to the Academy? Yes No PICK UP/DROP OFF INFORMATION Will your student be attending the Academy: After School Full Time What time will your student arrive at the Academy? What time will your student typically be picked up? EMERGENCY CONTACT INFORMATION Please identify two individuals (other than the parent or legal guardian) the WA[A[E Early Learning Academy may contact in the event of an emergency. Name: Cell Phone: Name: Cell Phone: Relationship to Student: Work Phone: Relationship to Student: Work Phone:

6 PARENT AUTHORIZATION Student s Name: Completed: WELA Location: AUTHORIZATION FOR SCREENINGS/ASSESSMENTS The Osage Nation WELA Program offers the following Health Screening. By checking the boxes, you are giving consent for your child to participate in these screenings. Type of Screening Vision Physical Speech Hearing Developmental Osage Language Height/Weight Dental Other MEDICAL AUTHORIZATION In case of an emergency, I authorize the Osage Nation WELA Staff to provide medical/dental treatment for my child from a qualified doctor, dentist, emergency room, EMT, or health care provider. I authorize the Osage Nation WELA Staff to administer basic first aid to my child in the classroom or in transit should an injury occur. AUTHORIZATION FOR RELEASE OF INFORMATION I authorize the Osage Nation WIC to release pertinent health information on my child to the Osage nation WELA. I authorize the Osage Nation WELA Program to share information with the Public School and WIC, such as my child s name and date of birth. I authorize the Osage Nation WELA and the local Public Schools to share pertinent social, developmental, medical, or any other information on a need to know basis.

7 OTHER PERMISSIONS AND RELEASES I give my child permission to take part in ALL Osage Nation WELA field trips, picnics, etc. Advance notice of one week will be given to parents/guardians. I give my permission for photo releases of my child relating to WELA. I agree to release my phone number/ address to the Parent Club and other local WELA Parents so that I may be contact about upcoming events and activities. SCREENING REFUSAL I,, refuse the following required Health Screenings, due to. ADDITIONAL STATEMENTS OF UNDERSTANDING I understand that Osage Nation WELA will make every attempt to contact me in case of an emergency and that when reached, my presence is necessary. The Osage Nation WELA is not liable for photos taken by other parents and posted on social media or other websites. I understand that speech, vision, hearing, and mental health professionals will be working with my child as needed.

8 ENROLLMENT CONTRACT Both parents, guardians, and other persons responsible for payments should read all the provisions of this contract, complete the required information, and sign and return the contract with the Enrollment Packet. A student is accepted for enrollment or re-enrollment when the entire enrollment packet has been delivered to WA[A[E Early Learning Academy, countersigned and dated. A copy of the accepted Enrollment Contract will be returned prior to the start of the January semester. No amendment to this Contract and no alteration or addition to the printed terms hereof will be effective without the express prior written approval of the WELA Director and the Osage Nation Director of Operations. Students Name: In consideration of the acceptance of this contract by the WA[A[E Early Learning Academy, the undersigned agrees to pay the required TOTAL TUITION for each month and any additional fees incurred and agrees to be bound by the provisions of this Contract. So long as tuition payments are not delinquent, tuition payments are due no later than the 10th of the following month at the rate of $25 a day for 6 weeks through 2 years of age. A charge of $18 a day for students 3 years through 4 years of age. Wrap around rate is $15 per day which will be dropped to $10 a day for Osage students. Enrollment and re-enrollment is conditioned upon the following terms: 1. Recommendation of WA[A[E Early Learning Academy is required for re-enrollment of currently enrolled students. 2. Tuition payments must be received by WA[A[E Early Learning Academy on or before each monthly due date. Tuition for students entering WA[A[E Early Learning Academy after the start of the month will be prorated based on the number of attendance days remaining in the month after entry compared with the total attendance days in the month. Tuition will not be charged on Osage Holidays, days when the Nation is closed due to inclement weather, professional days, or on other days as identified by the WA[A[E Early Learning Academy Acceptance of enrollment constitutes an agreement to pay each full academic month s account, comprised of both TOTAL MOTHLY TUITION and all related fees and expenses of the student. WA[A[E Early Learning Academy is entitled to be reimbursed for any attorney s fees and costs incurred in the collection of any unpaid balance.

9 4. The student and the students family agree to comply with and be subject to WA[A[E Early Learning Academy rules and policies as set forth in the Parent Handbook, as amended from time to time. 5. An account is considered delinquent if not paid on or before the 10th calendar day of each month. If your account is not paid by the 10th of each month your child will not be able to return until the balance is paid in full. Whenever a tuition or fee account becomes past due for a period of 30 days from its due date, then the remaining balance will be sent to the Attorney General s Office for collection and the student will be dismissed. 6. Parents/Guardians receiving financial assistance are responsible for all co-payments, fees, and unpaid balances under the above terms of this contract. 7. The undersigned hereby expressly recognizes that the benefit sought or presently enjoyed by the undersigned from the Osage Nation government, to wit: enrollment of my child in WA[A[E Early Learning Academy is a privilege and a benefit, regardless of whether the undersigned is a natural artifact person or entity, and further regardless of whether the undersigned is of Indian or non-indian blood, descent or legal character, the undersigned hereby stipulates and agrees that jurisdiction over all matter and disputes arising out of exercise of such a benefit and privilege shall vest in the Osage Nation laws, codes regulations, policies and procedures governing such benefits, privileges and activities. The undersigned further expressly waives all further rights to contest the jurisdictions of the Osage Nation Courts over any such matter, disputes, actions, or decisions of any branch of the Osage Nation Government. Father/Guardian or Person Responsible for Payment Mother/Guardian or Person Responsible for Payment WA[A[E Early Learning Academy Center Manager

10 ALL ABOUT ME My name is: I was born on: I have members in my family. I am months/years old. My family background is: My favorite things: Pet Color Food Toy Things my teachers need to know about me: